Orientation of medical trainees to a new clinical environment (the ready-steady-go model): a constructivist grounded theory study

Background High-quality orientation of trainees entering a new clinical workplace is essential to support education and patient safety. However, few consultants receive extensive formal training to support new trainees and must create their own ways of integrating newcomers into their clinical team and work environment. We aim to conceptualise the strategies consultants use in the early stages of working with new trainees that will be useful for future faculty development in this area. Methods We used constructivist grounded theory (CGT) methodology by interviewing fifteen consultants in three medical specialties, to explore how trainees are integrated into a new clinical environment. We used CGT principles and procedures (iteration, constant comparison, and theoretical sampling) to analyse and construct a conceptual interpretation of the empirical data. Results Consultants’ central concern when introduced to a new cohort of trainees was that they had the required knowledge and skills (ready), were adapted and integrated into the new workplace and clinical team (steady), and safely participating in practice (go). Consultants used two broad strategies: formal orientation and informal orientation. Both these approaches had the common goal of intensifying interaction between consultants and trainees to get trainees to a position where they were ready, adapted, integrated, and participating safely and efficiently in practice. Several disruptors were identified by participants that delayed and sometimes completely inhibited the orientation process. Conclusions The model of orientation constructed through this research could be a valuable tool to support faculty development initiatives, the reflective learning practice of clinical supervisors, and curriculum design. The disruptors were identified as valid priorities for improving trainee orientation in postgraduate medical education. Future research should involve a longitudinal approach to explore trainee engagement with orientation upon entering a new clinical workplace.

Transforming Continuing Medical Education in the COVID-19

Medical education is not immune from the heartaches produced by abrupt contemporary changes in our world, such as the COVID-19 pandemic. Unexpectedly, and on very short notice, people can no longer teach or learn alongside other people. The impact on the heart of the educational processes of the health professions is unprecedented. The key concerns of yesterday, such as the need to enhance bedside learning or to enhance the experience of students in the clinical setting, in the clinical workplace, have a different meaning. Medical educators can leverage technology to enhance medical education at both undergraduate and graduate levels. Although the most recent initiatives, such as remote transmissions, have been introduced for a long time, traditional classes, lectures, and face-to-face didactic tutorials continue to be the most important cornerstone of medical education both in our country and abroad. The COVID-19 pandemic has posed challenges in medical education globally. Each society has responded according to its possibilities and needs to take advantage of this situation as a learning opportunity, continue with education, and incorporate students as health workers in the countries where it was necessary.

Sustainability in Quality Improvement (SusQI): challenges and strategies for translating undergraduate learning into clinical practice

Background The healthcare sector is a major contributor to climate change and there are international calls to mitigate environmental degradation through more sustainable forms of clinical care. The UK healthcare sector has committed to net zero carbon by 2040 and sustainable healthcare is a nationally mandated outcome for all UK graduating doctors who must demonstrate their ability to address social, economic, and environmental challenges. Bristol Medical School piloted successful Sustainability in Quality Improvement (SusQI) workshop, but identified challenges translating classroom learning into clinical practice. This paper aims to identify and address those challenges. Methods We conducted five focus groups that identified and iteratively explored barriers and facilitators to practice among medical students, comparing a range of experiences to generate a conceptual model. We then combined our findings with behaviour change theory to generate educational recommendations. Results Students that applied their learning to the clinical workplace were internally motivated and self-determined but needed time and opportunity to complete projects. Other students were cautious of disrupting established hierarchies and practices or frustrated by institutional inertia. These barriers impacted on their confidence in suggesting or achieving change. A minority saw sustainable healthcare as beyond their professional role. Conclusions We present a series of theoretically informed recommendations. These include wider curricular engagement with concepts of sustainable clinical practice; supportive workplace enablement strategies such as workplace champions and co-creation of improvement goals; and time and headspace for students to engage through structured opportunities for credit-bearing project work.

Transfer of communication teaching skills from university to the clinical workplace – does it happen? A mixed methods study

Background Communication skills learned in the classroom do not transfer easily into clinical practice because they are not reinforced by teachers in the workplace setting and because lack of faculty training restricts the transfer of communication skills in real patient encounters. Trained university-based communication skills teachers often work simultaneously as doctors in clinics. This study explored if and how the skills of these teachers play a role in communication skills training in the clinical workplace. Methods We used an exploratory sequential design: a mixed method approach that combined a survey with communication skills teachers, and qualitative individual interviews with these teachers and their educational leaders in clinical departments. The questionnaire was analysed using descriptive statistics. The interviews were analysed using content analysis. Results The response rate was 34 %. A majority (93 %) used their communication skills when communicating with patients and relatives. Less than half taught communication in clinical departments. Approximately half of the respondents stated that encouragement from their leaders or colleagues would inspire them to use their teaching skills in the workplace. However, only 20 % had told their leaders about their competencies in teaching communication. One third thought that they needed further teacher training to teach in the clinical workplace. Qualitative analysis showed that teaching opportunities existed but mainly consisted of random, one-off sessions that came about through the initiative of the communication skills teachers themselves. The teachers described several barriers, such as the challenge of teaching colleagues, as communication relates to identity and hierarchical structures, as well as a lack of requests from colleagues or management, and department culture prioritizing topics relating to medical expertise. None of the educational leaders made use of the teachers’ specific communication skills in a structured way: some saw it as unimportant, while others saw it as a potential resource. Conclusion Transfer of the teaching skills of communication skills teachers trained for university-based clinical communication training happened, but to a limited degree. Although both opportunities and barriers for transferring communication skills existed, barriers seemed to dominate, and opportunities for communication skills training in the workplace setting were not used to their full potential.

How medical students’ early workplace experience could benefit the NHS

As senior medical students who have had the privilege of undergoing early year clinical workplace experience, we believe that this opportunity medical students have through experiencing the ‘frontline’ could be utilised advantageously by the National Health Service (NHS). A system under pressure with depleting resources seemingly persists to be a constant theme that surrounds the NHS. Due to such issues, improvements in all sectors are sought, including costs, patient experience and communication between healthcare professionals. Through this article we highlight and analyse how medical students’ early workplace experience, as presented by Leedham-Green et al., could benefit the NHS through tackling some of the challenges mentioned prior.

Design and first impressions of a SPOC in clinical workplace learning (Preprint)

BACKGROUND Clinical workplace learning takes place in a dynamic and complex learning environment that is designated as site for patient care and education. Challenges in clinical training can be overcome by implementing blended learning, since it offers flexible learning programs suitable for student-centered learning, online collaboration and peer-learning. OBJECTIVE This article describes the design process of a Small Private Online Course (SPOC) from a theoretical and practical perspective, its’ integration in a clinical clerkship in internal medicine and the first impressions of clerks (n = 20) on using the SPOC. METHODS The design of the SPOC was based on 1) general theoretical principles that learning should be constructive, contextual, collaborative and self-regulated and 2) self-determination theory to stimulate intrinsic motivation. Clerks’ impressions were evaluated with an online questionnaire and group interview. RESULTS The evaluation shows that the SPOC is a useful and accessible addition to the clinical learning environment, providing an alternative opportunity to improve knowledge and skills. Online collaboration through interaction with peers in the SPOC was perceived as less effective, since student feedback was felt inferior to teacher feedback. Self-regulated learning and autonomy could be improved since more flexible and just-in-time learning were preferred. CONCLUSIONS This article shows how design principles can be successfully applied to a SPOC to optimize its integration in clinical workplace learning. Further research is needed to improve online collaboration and interaction in our course.

Sustainability in Quality Improvement (SusQI): Challenges and Strategies for Translating Undergraduate Learning Into Clinical Practice

Background The healthcare sector is a major contributor to climate change and there are international calls to mitigate environmental degradation through more sustainable forms of clinical care. The UK healthcare sector has committed to net zero carbon by 2040 and sustainable healthcare is a nationally mandated outcome for all UK graduating doctors who must demonstrate their ability to address social, economic and environmental challenges. Bristol Medical School piloted successful Sustainability in Quality Improvement (SusQI) teaching, but identified challenges translating classroom learning into clinical practice. This paper aims to identify and address those challenges. Methods We conducted five focus groups that identified and iteratively explored barriers and facilitators to practice among medical students, comparing a range of experiences to generate a conceptual framework. We then combined our findings with behaviour change theory to generate educational recommendations. Results Students that applied their learning to the clinical workplace were internally motivated and self-determined but needed time and opportunity to complete projects. Other students were cautious of disrupting established hierarchies and practices or frustrated by institutional inertia. These barriers impacted on their confidence in suggesting or achieving change. A minority saw sustainable healthcare as beyond their professional role. Conclusions We present a series of theoretically informed recommendations. These include wider curricular engagement with concepts of sustainable clinical practice; supportive workplace enablement strategies such as workplace champions and co-creation of improvement goals; and time and headspace for students to engage through structured opportunities for credit-bearing project work.

Residents’ identification of learning moments and subsequent reflection: impact of peers, supervisors, and patients

Background The clinical workplace offers residents many opportunities for learning. Reflection on workplace experiences drives learning and development because experiences potentially make residents reconsider existing knowledge, action repertoires and beliefs. As reflective learning in the workplace cannot be taken for granted, we aimed to gain a better insight into the process of why residents identify experiences as learning moments, and how residents reflect on these moments. Methods This study draws on semi-structured interviews with 33 medical residents. Interviews explored how residents identified learning moments and how they reflected on such moments, both in-action and on-action. Aiming for extensive explanations on the process of reflection, open-ended questions were used that built on and deepened residents’ answers. After interviews were transcribed verbatim, a within-case and cross-case analysis was conducted to build a general pattern of explanation. Results The data analysis yielded understanding of the crucial role of the social context. Interactions with peers, supervisors, and patients drive reflection, because residents want to measure up to their peers, meet supervisors’ standards, and offer the best patient care. Conversely, quality and depth of reflection sometimes suffer, because residents prioritize patient care over learning. This urges them to seek immediate solutions or ask their peers or supervisor for advice, rather than reflectively deal with a learning moment themselves. Peer discussions potentially enhance deep reflection, while own supervisor involvement sometimes feels unsafe. Discussion Our results adds to our understanding of the social-constructivist nature of reflection. We suggest that feelings of self-preservation during interactions with peers and supervisors in a highly demanding work environment shape reflection. Support from peers or supervisors helps residents to instantly deal with learning moments more easily, but it also makes them more dependent on others for learning. Since residents’ devotion to patient care obscures the reflection process, residents need more dedicated time to reflect. Moreover, to elaborate deeply on learning moments, a supportive and safe learning climate with peers and supervisors is recommended.

Simulation of Pediatric Life-Threatening Emergency Scenarios (SimPLES): The Development, Implementation, and Evaluation of an Undergraduate Immersive Simulation-Based Educational Intervention

Background: Clinical exposure to acutely unwell pediatric patients is often limited during undergraduate medical training. Although limited within undergraduate pediatric curricula, simulation-based education (SBE) offers a tool with which such exposure can be achieved in a safe and effective learning environment. This study describes the development, implementation, and evaluation of an undergraduate multi-center immersive pediatric SBE course. Objectives: We sought to increase medical students’ exposure to acutely unwell pediatric patients and provide practical experience to improve their understanding of the importance of non-technical skills within the clinical workplace, such as teamwork, communication skills, leadership, and situational awareness. Furthermore, we sought to evaluate the impact on students’ confidence in assessing and managing acutely unwell pediatric patients while exploring their perceptions and opinions of the course. Methods: The present study included all final-year students who were on a pediatric clinical placement during the study period. Tutorials on pediatric A-E assessment and fluid management were followed by a series of immersive simulation scenarios and structured debriefs, concentrating on the importance of non-technical skills in the clinical workplace. Also, some mini-tutorials were incorporated into the course design, focussing on the technical and pathophysiological aspects of each presentation. We employed a mixed-method research methodology to evaluate the impact of the course. Also, anonymized post-course and free-text feedback was sought to explore students’ experiences and perceptions of the course. Results: All 80 students completed the pre and post-course confidence questionnaires, reporting statistically significant improvements in confidence across all 11 domains tested. Thematic analysis of the qualitative data identified six core themes: knowledge acquisition, the value of debriefing, the importance of non-technical skills, the value of faculty expertise, the value of repeated practice, and opportunities for exposure to pediatrics. The innovative post-scenario mini-tutorials were favorably received. Conclusions: Our study shows that immersive SBE can improve medical students’ confidence in managing pediatric emergency scenarios. Also, incorporating mini-tutorials within an immersive simulation course design in an undergraduate setting can be helpful and well received by students.